Inspection on 31/07/08 for Whitby Drive (8)

This inspection was carried out on 31st July 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitby Drive (8) 25/07/06

Whitby Drive (8) 13/10/05

Whitby Drive (8) 18/05/05

Whitby Drive (8) 07/12/04

Whitby Drive (8) 01/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOME ADULTS 18-65 Whitby Drive (8) Biddick Washington NE38 7NW Lead Inspector Elsie Allnutt Key Unannounced Inspection 29th July 2008 10:00 Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitby Drive (8) Address Biddick Washington NE38 7NW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 4172448 P/F 0191 4172448 c.i.c@whitbydrive.uk www.c-i-c.co.uk. Community Integrated Care Tammy May Thompson Care Home 5 Category(ies) of Learning disability (5), Physical disability (3) registration, with number of places Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD, maximum number of places: 5 2. Physical disability - Code PD, maximum number of places: 3 The maximum number of service users who can be accommodated is: 5 25th July 2006 Date of last inspection Brief Description of the Service: 8 Whitby Drive is a home that provides a service for 5 people with learning disabilities all of whom have high dependency levels. The home is situated in a cul-de-sac of detached houses and bungalows. It is close to a school, pub and local shops and is close to local transport that provides access to Sunderland and Newcastle City centres. The building is a bungalow with a large conservatory at the back that accommodates a ball pool. There is an overhead tracking system and several other mobility appliances, which meet the needs of the service users. Each person living at the house has a single bedroom with the facility to lock the door for added privacy. There are also shared facilities that include a large lounge/ dining area, conservatory, kitchen, utility room, bathroom and toilets. Attractive well-kept gardens are accessed via French windows from the conservatory and a ramped access via the side of the building. The home has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met and a copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home are £952 per week. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 19th May 2008. During the visits we: • • • • • • Talked with people who use the service, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: 8 Whitby Drive is a home that is safe and comfortable and is well looked after. The rooms are large which means there is plenty of space for people who need to use a wheelchair to get around. Staff and service users get on together very well and make visitors to the home feel very welcome. The garden that gives service users an area that is attractive and safe is well looked after and has many nice plants and flowers. These can be seen and enjoyed from inside the building. Service users are supported to take part in activities both in the home and in the local community and these have recently been further developed. Service Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 6 users now go on holidays of their choice and destinations have included places they have never visited before. This means that they are enjoying new experiences. One service user who had never travelled out of England said, “I went to Spain for my holiday.” Service users are supported in the right way according to their needs and the way that they wish and staff are trained how to do this well. Healthcare professionals confirmed that, in their opinion the home supports service users’ healthcare needs well, regarding service users’ different abilities and their different preferences. They also felt that staff have the skills and experience to support service users’ both social and healthcare needs. Staff help each service user to keep in contact with their family and friends and they are always made to feel welcome at the home. What has improved since the last inspection? Service users and their representatives receive contracts from the home that explains the home’s terms and conditions when they first move in. This means that anyone choosing to live at this home knows what is expected of them and what they are responsible for. The care plans have been improved and they now inform staff clearly how service users need to be supported. Service users now take an active part in developing their plans of care. This means that the way they like to be supported is listened to and if they need support to explain this other people who know them well are available to support them with this process. The manager is supporting and training staff how to use the new care planning system so that information is recorded accurately and the written guidelines in the plans are followed in the right way. This means that service users will receive the care they need in a consistent way. The manager has worked hard to establish a more consistent staff team. The previous high turnover of staff has now settled and there is little staff sickness. This means that service users receive care from staff that they know and trust and who are reliable. Staff who work night shift now remain awake all night so that if service users need support or wish to get up for a drink during the night staff are available to support them with this. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 7 There has been a positive change is some care practices. Staff are guided and supported to have a better understanding of how and why the home’s policies and procedures guide them to work in certain ways. The outcome of this has meant that service users are supported by staff who are better informed of the values and attitudes needed when working at this home and when supporting service users to enjoy lifestyles that are varied and interesting. As result service users are more empowered to live lives that they choose, enjoy, that makes them feel good and that is their right. Staff are now working together as a team and get on well together. The health and safety issues addressed at the last inspection have been addressed. This includes the fitting of window restrictors and the appropriate disposal of rubbish. This means that service users live in an environment that is safer. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment process is in place that confirms the home can meet service users’ needs and service users are made aware of the home’s terms and conditions. EVIDENCE: A vacancy in the home has been filled since the last inspection. Prior to the service user moving in the home received important information about them so that a decision could be established whether their needs could be met. Assessments from the referring agency and the healthcare professionals involved in the service user’s care were received by the home. These are in detail and identify the needs and related risks well. A care plan that relates to the assessed needs has been developed and is now in place. A planned introduction to the home, that involved several visits, supported the service user through a gentle transition process and gave them and the other service users time to get to know each other and establish whether everyone was compatible. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 10 A contract informs the service user of the home’s terms and conditions as well as details of the fees charged and how these are to be paid. A separate contract details how the service user contributes to the running of a vehicle to be used by them. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans, that are the outcome of ongoing assessment, guide staff to appropriately support service users’ care needs, promote their independence by safely addressing risks and enable staff to support service users to make choices about their lives. EVIDENCE: The manager has worked hard to establish a new care planning system for this service. This is a very good system and is based on service users assessed needs and is service user lead. New care plans are in place for all service users and they are developed so that the service user guides staff to support them in a way that meets their assessed personal, social and healthcare needs and their personal preferences. They are extremely detailed and the information recorded in them is current, and clearly and effectively guides staff to support service users. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 12 Service users are empowered to lead their care plans. They are written with a person centred approach and they are illustrated with pictures so that service users, as far as possible, have access to what is written about them. Information in a file called “All about me” very clearly informs the reader about the person, their needs, how they communicate, their preferences, important people and events in their lives and their aspirations. The photographs and pictures used clearly illustrate the printed words. Although all of the service users who live at this service have high needs and three have complex needs, all are supported to develop and maintain their independence. Guidelines are in place that leads staff to reduce any assessed risks so this can be achieved safely. Such guidelines are an integral part of the care plan. There are plans to establish a key worker system and following this staff are to take responsibility for the general monitoring and reviewing of the care planning system. Although staff have previously received training regarding person centred planning, the manager plans to give further training and guidance, regarding the key worker system, the setting and the achievement of individual goals and how they fit in with the overall care planning system. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live appropriate and fulfilling lifestyles both in their own home and the local community, while at the same time they are supported to maintain relationships with family and friends. Furthermore meals are healthy, nutritious and attractive, and are prepared to meet service users’ individual dietary needs. EVIDENCE: Service users have been supported through the person centred planning process to develop individual activity programmes. Such programmes are recorded in their care planning documents and used as a guide in a flexible way. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 14 A process referred to as “community mapping” and individual service user’s “circle of support” has supported service users to find new opportunities and the development of positive relationships. “Community mapping” is where service users’ individual likes and preferences are matched with different and varied facilities in the community. “The circle of support” is made up of the people who know the service user well and assist them to make individual choices and decisions during the person centred planning process. The names of the people involved in this process are recorded in the individual care plans. As a result of this process service users, who may not be able to communicate their choices effectively are supported to choose their own leisure, education and employment opportunities including their own cultural and religious activities. This has proved to make a marked difference to the social and cultural lives of the people living at this service. Service users now take part in a variety of activities that have in effect resulted in the positive development of the individuals. One service user with the support of a member of staff answered the front door with a very pleasant welcoming smile. Another was enthusiastic to discuss a recent holiday in Spain, which had been their first experience abroad and travelling by air. They said; “It was great.” Other holidays which were individually chosen, include a visit to London to stay in a four star hotel while seeing the musical The Sound of Music and a stay at one of the Centre Parks at Blackpool. Two service users supported by staff went out for the weekly food shopping and had their lunch out while others relaxed at home watching TV and listening to music. One service user now regularly goes to a local disco while other activities now accessed include swimming, visiting a local sensory room and hydrotherapy pool, bowling, visiting cinemas and the theatre. Families continue to visit the home, some regularly and some on special occasions. A local advocacy service has been approached for one service user but unfortunately due to lack of resources they will only become involved if an issue arises. A great effort has been made to develop new menus that are appropriate for service users’ individual nutritional needs. A dietician has delivered training to Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 15 staff regarding the importance of good nutrition and how this applies to the individual service users’ needs. The dietician also assisted staff to develop a menu file that is accessible to service users. This has resulted in individual needs now being addressed and menus being adapted to meet these. For example some service users might need foods that are high in calories where some need to monitor their calorie intake, some need food moist and others need their food to be cut up. Staff stated that they are now more aware of the importance of a good balanced diet and how this should be presented to the individual service user. Individual nutritional needs are recorded in good detail in the care plans. One service user who often demonstrated challenging behaviour at the table has now learned to eat food independently and the challenging behaviour has now ceased. This has been the outcome of a consistent approach by the staff team. A midday meal was shared with the service users and staff. The food was nutritious and attractively served and the atmosphere around the table was enjoyable and pleasant. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are met in a flexible but consistent manner, reflecting a healthy lifestyle. The medication arrangements in place are appropriate to the needs of service users. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Visits to the GP, dentist’s, opticians and other healthcare professionals are recorded in individual care files, with the outcome of the visit. Everyone at the home is currently enjoying good health and they are living healthy lifestyles. Staff work hard to promote this and at the same time work closely with healthcare specialists, including physiotherapists, speech therapists and dieticians, from whom they receive knowledge and guidance. Healthcare needs are clearly recorded in Health Care Action Plans that are recorded together in one file. The staff and the manager feel that having all relevant information about a person’s healthcare needs together proves helpful Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 17 when service users attend healthcare appointments and in the event of a service user being admitted to hospital. Staffing resources and duties have been monitored and reviewed regarding the changing needs of service users. The home recently changed the duties of the night shift staff and the member of staff on duty now works a “waking” night instead of a “sleep in.” This change has resulted in service users’ individual needs being more appropriately addressed during the night hours. For example one service user who was beginning to become distressed in the night now occasionally likes to get up, sit in the chair and have a drink. Having the support to do this has resulted in positive outcomes for the person. The guidelines in the care plans cover 24 hours and are used as a tool to guide staff to approach and deal with behaviours demonstrated by individual service users. Any health or behaviour changes that are observed are clearly recorded and if needed action is taken to gain specialist healthcare advice. The guidance given is recorded in the care plan. Staff are guided how to address epileptic seizures and how to reduce anxieties. The healthcare action plans clearly guides staff to address these appropriate to the individual service user with positive effect. Special appliances are available for service users who need them and an occupational therapist carries out assessments in relation to these. Appropriate appliances and equipment were put in place prior to a service user recently moving into the home. Two service users use bedrails that are integral to their individual beds and appropriate health and safety checks are in place regarding the use of these. The manager has noted that one service user’s changing behaviours at night need to be supported by carrying out a risk assessment regarding the use of the bedrails.The manager agreed to address this. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries and are signed by appropriate staff. All staff have completed training regarding the safe administration of medication and the manager monitors compliance with the home’s procedures. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place that helps to protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a comprehensive complaints procedure that is in picture format in an attempt to make it more accessible to the service users. Staff are aware of signs given by service users when they are not happy or are showing concern about something. This is recorded in individual care files and acted upon. Staff have received training regarding the local authority’s Protection of Vulnerable Adults (POVA) procedures and are able to confirm the action they would take if an abusive incident was observed or reported to them. These policies are regularly discussed in staff meetings. At induction staff are made aware of the GSCC Codes of Practice so that they know the principles they are expected to work to. The home has a Gender Sensitive policy that further protects service users from possible abuse. The home keeps clear records of service users’ financial affairs. These are appropriately kept, up to date and show clearly how service users’ monies are spent. Each service user has a bank account where any money belonging to them is paid into. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 19 All staff receive training regarding challenging behaviour and guidelines are in place regarding how individual service users’ challenging behaviours are to be addressed. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable, clean and decorated and furnished to a good standard. It provides service users with spacious, private and communal spaces that are safe in which to live. EVIDENCE: The standard of the furnishings and fittings in this home are good, presenting an attractive and comfortable environment for service users to live. New wood flooring has replaced some of the carpets and this is practical regarding the use of wheelchairs in the home. A new conservatory has replaced the former leaking conservatory, however when the door is left open the stone steps leading into the garden presents a risk to one service user in particular. The home is seriously considering how this risk can be addressed. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 21 Fans in the conservatory keep this area from overheating and allow service users comfortable access in hot and sunny weather. New doors leading into the conservatory have now replaced the sliding doors and are more easily and safely used to close off this area if needed. The gardens surrounding the home are neatly kept, however discussions addressed how the front of the house, if more attractively decorated with colourful plants and flower pots, could improve the entrance to the home and promote a more positive image of the people living and working here. The manager agreed to address this. There are two bathrooms in the house one that has a special bath suitable for people with physical disabilities and another with an ordinary bath. During the last maintenance check the contractor assessed that the floor beneath the bath needed attention as it was showing signs of movement. In addition to this there are signs of mould growing around the outside base of the bath that needs attention to maintain infection control. The manager confirmed that the state of the bath and the floor has both been reported to the appropriate people. Since carrying out this inspection the service manager has confirmed that the floor under the bath has been repaired and made safe. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment and selection procedures, regular training opportunities and supervision ensures that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: Staff work with service users in a sensitive and competent way. Signed declarations showed that at the induction stage staff are issued with copies of the GSCC Codes of Practice and their practice reflects their awareness of these. The staff rota confirmed that at least three members of staff are on duty on each shift, however the manager at times is included in this number. Three members of staff plus a student nurse placement, who was not counted on the rota, were on duty. In addition to this the manager was also available. This ratio of staff, considering the planned activities for the day, addressed the needs of the service users effectively. However the manager stated that as Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 23 service users are now starting to develop more active and individual lifestyles outside of the home, plans are in place to review the ratio of staff needed to effectively support this development. This is particularly important considering the high and for some, complex needs of the service users. Staff are up to date with mandatory training and all staff are qualified in NVQ 2 and some are now working towards NVQ 3. Recent training includes the safe handling of medication, specialist training regarding learning disabilities, mental health awareness, E Learning and the awareness of the Mental Capacity Act. There are plans in place for staff to attend training regarding Equality and Diversity. A training matrix demonstrates the training staff attend and the dates of future training. The home follows the company’s robust recruitment procedures and staff files include completed application forms, 2 references and satisfactory CRB checks. However not all of the application forms demonstrate clear records of employment and there was no evidence that this had been explored and recorded. The manager agreed to address this. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager, who has worked hard to develop an informed and supportive staff team, provides very good leadership and runs a service that has effective monitoring systems that are focussed on the best interests of the service users. EVIDENCE: The manager has been the registered manager for this home since September 2007. She is fully qualified having achieved the Registered Managers Award (RMA) and NVQ4 in Care. While in a senior position at a previous home the manager funded the RMA independently. She has also recently completed the training to be a facilitator for Moving and Handling and is currently awaiting final assessment. Other training related to Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 25 the role as manager includes the Safeguarding Adults Alerter Course, The Mental Capacity Part 2, Supervision and Appraisal, Budget Management and training in The Role of CSCI and Social Care and Governance. She is currently attending IT training. The manager interacts with service users and staff positively and in a supportive way. Staff feel well supported and that they can go to the manager for guidance and advice when needed. The manager is “passionate about her job” and has worked hard with staff to establish the home’s policies and procedures so that they are followed in an effective way for the best outcomes for service users. The policies and procedures are regularly reviewed and brought up to date when necessary. They are discussed in staff meetings and in individual supervision sessions where staffs’ understanding of them is confirmed. The manager is up to date with changes in legislation, new ideas and policies regarding working with people with learning disabilities and she has a good understanding and awareness of the principles of the Government’s White Paper Valuing People. This knowledge is shared with staff. There is a good quality assurance system in place, the outcomes of which are recorded. The system is monitored internally monthly by the manager and annually by an external person. This ensures that the home’s policies and procedures are put into practice and that the service is led in the best interests of the service users. Completed surveys inform the manager of the service users and their relatives/advocates service satisfaction. Risks identified throughout the home are monitored and generally addressed well. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 3 3 3 X 3 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000015756.V367754.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 4 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Whitby Drive (8) Score 3 3 3 X 3 X 3 X X 2 X Version 5.2 Page 27 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19(1) Requirement The registered manager must ensure that any gaps evident on staff application forms, regarding their work history, are explored and the reasons recorded. The registered manager must ensure that the fungi, surrounding the outside base of the specialised bath, must be addressed and got rid of so that infection control is maintained. Timescale for action 31/08/08 2 YA42 13(3)(4)(c) 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA9 YA9 Good Practice Recommendations The plans to reassess the risks regarding the use of bedrails should go ahead. So that the conservatory door can be left open in very warm weather, the risk presented to service users in doing this should continue to be addressed and strategies put in place to reduce the risk. DS0000015756.V367754.R01.S.doc Version 5.2 Page 28 Whitby Drive (8) 3 YA33 It is strongly recommended that the number of staff needed on each shift to support service users to develop their chosen lifestyles is reviewed and at the same time, the time needed by the manager to address her role effectively, is taken into consideration. Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whitby Drive (8) DS0000015756.V367754.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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